1 Inguinal Hernia RepairMatt Stephenson and Stephen Whitehead
Video | 25 min 1 s
Stephen Whitehead, Consultant General Surgeon
Conquest Hospital, St Leonards-on-Sea
Filmed at Bexhill Hospital
IntroductionInguinal hernia repairs are easy aren’t they? Ermm... no, not really. Or at least not to begin
with. The learning curve for an inguinal hernia is actually quite steep, probably because
they can look so different every time you open the inguinal canal—it can be very frus-
trating. We’ve all been there. It never looks as clear as it does in the textbooks or atlases;
it’s almost as if the people whowrote those books had never seen one in real life. Like the
appendicectomy, the inguinal hernia repair can be really quite difficult for the beginner, yet
these two operations are still left to the most junior surgeons, often without supervision.
Nevertheless, take heart that everyone struggles to begin with and that once you’ve
seen and done a few it will become second nature. Showing an inguinal hernia on video
is actually rather tricky as the wound is quite small and the anatomy quite complex. Like
many of the videos, you’ll probably need to play it through a few times to take everything
in. Here we show one whole operation all the way through and then in the Inguinal Hernia
Extras video, a female inguinal hernia repair, an inguinoscrotal hernia and another
indirect hernia so as to go over separating the cord and separating the sac—the bits
everyone gets stuck on. Once you can do this, you’ve cracked it.
We are of course showing the Lichtenstein mesh repair—the most commonly used
technique in the UK.
ProcedureWith the patient supine and under gen-
eral or local anaesthesia, shave, prep
and drape the groin. Note the bony
landmarks of the anterior superior iliac
spine (ASIS) and the pubic tubercle.
The inguinal ligament runs between
these two. Your incision therefore needs to
be a fingerbreadth or two above and
parallel to the medial half to two-thirds of
this.
Incise through skin,Camper’s fascia
and Scarpa’s fascia (which is white and
membranous) then through fat. It’s likely
How to Operate: for MRCS Candidates and Surgical Trainees, First Edition. M. Stephenson. ª 2011 John Wiley & Sons, Ltd.
Published 2011 by John Wiley & Sons, Ltd.
COPYRIG
HTED M
ATERIAL
you’ll encounter a chunky vein running
vertically in your wound—ligate and divide
it if it’s substantial enough, otherwise use
diathermy. Keep incising down to exter-
nal obliquemaintaining haemostasis as
you go. If the abdominal wall is quite thick,
inserting a Travers retractor at this
stage can be quite helpful.
You’ll recognise the aponeurosis of
external oblique by the fibrous strands
running parallel to your wound. Once
you’ve reached it, you need to decide the
level at which you’re going to open it.
Trace the fibres down towards the pubic
tubercle and look for where they decus-
sate. That’s what the external ring is, a
triangular gap where the upper fibres
plunge inferiorly to the lateral tip of the
pubic tubercle and the lower fibres criss-
cross over and leap over to attach more
medially. You can actually see this decus-
sation and it marks the apex of the external
ring where the hernia may be popping out.
So, make a stab incision in the line of
the fibres at the level of the apex of the
external ring. Take a small clip and clasp
the upper leaf and the samewith the lower
leaf. Using closed dissecting scissors
bluntly create a plane below the external
oblique in the line of the canal, thus sepa-
rating off the cord or the ilioinguinal
nerve, which may be sticking to it just
below the surface. Score with the scis-
sors inferomedially down to the external
ring and the same superolaterally. With
upward traction on the external oblique
clips gently dissect beneath external
oblique, superiorly and then inferiorly, thus
creating a plane beneath it. Insert the
Travers’ retractors into this plane. Con-
gratulations, you have now opened the
inguinal canal. But, I’m sorry, you haven’t
fixed the patient yet; now comes the hard
part. You look into the canal and unless
you’re very lucky, you just see a big bul-
ging muscley, fatty, tissuey lump. What
you’re looking at is two things: the cord
and the sac and they may be intimately
entwined.
The first thing to do is separate the cord
(1/2 sac) from the pubic tubercle.
Begin by gently snipping, with the tips of
The bulging cord is shown outlined. Note the ilioinguinal nerve running over the front of it and the
lower fibres of transversus abdominus which at their most inferior part form the conjoint tendon
along with the internal oblique.
2 | General
your scissors, any loose connective tissue
that you can obviously see tethering the
cord (1/2 sac) down to the posterior wall
of the inguinal canal. Next you need to
hook the cord (1/2 sac—that’s getting
boring, assume we mean potentially both
for now) up with your finger. Insert your
index finger into the inguinal canal with
fingernail lying against the inside of the
inguinal ligament with fingertip pointing
to the pubic tubercle. Push your finger
under the cord keeping your fingernail
apposed to the pubic bone (there should
be almost nothing between your fingernail
and the bone—all the vessels etc. arching
over the tubercle are staying with the
cord—you don’t want to leave them
behind). Hook up the cord with your finger
and gently probe with the fingertip until
you see it emerge on the medial side of
the cord. There is a knack to it and it
comes with practise. It helps if you keep
the axis of your finger horizontal, that is in
line with the superior edge of the pubic
bone, rather than pointing it upwards as
you may just be pushing straight into a
direct hernia.
Once the cord is suspended over your
hooked finger you need to work out
what’s cord and what’s sac. To do this
you first need to decide—is it an indirect
hernia or a direct hernia? In an indirect
hernia, thewhole cord is bulky but it has
a relatively narrow base (well, the same
width as the rest of the cord) emerging
from the deep ring and you can easily peel
it off the posterior wall, which isn’t bulging
out. In a direct hernia however you will
either feel a thin cord and behind it the
posterior wall is bulging out, or, more
likely, the whole cord seems to be coming
from a very wide base stretching out
over the whole of the back wall. This is
because the sac emerging from the pos-
terior wall has fused with the cord struc-
tures running past it. If this is the case,
hook the cord inferoanteriorly and you’ll
see the posterior wall tethered up to the
back of it. Dissect the connecting
strands with scissors all the way back to
the deep ring and the direct hernia bulge
will fall back into its rightful place on the
posterior wall and the cord will thin out.
You may of course find both.
So, for the indirect hernia, the first part
of this game is to find the white edge of
the peritoneal sac. Everyone has their
own favourite method of doing this. Here
we show dissecting scissors gently
peeling off the outer layers of the cord, all
those cremasteric fibres, by firmly strok-
ing the closed tips in the direction of the
cord. Some people like to pinch the cord
between finger and swab to firmly wipe
off the outer layers and systematicallyThe cord has been hooked up by the index
finger.
Inguinal Hernia Repair| 3
go from one edge transversely across to
the other, thinning out the cord as they
go. However you do it, you’re looking
for a white edge somewhere within the
cord.
Once you see it, get a clip on it, get two
if you can. Lift them up and gently dissect
all the adjacent tissue away from the
white edge, keeping close to the white
edge, until the white edge gets bigger and
bigger and more and more separate from
the rest of the cord. If you’re not sure
where it’s going, for example if you think
it’s going all the way down into the scro-
tum, you can open it and put your finger
inside. Get the whole sac dissected out
down to the level of the deep ring.
Twist the sac several times thus
pushing any contents back into the
abdomen and transfix it at the base with
an absorbable suture such as 2–0 Vicryl.
Cut the stalk of the sac first, not the
stitch, that way you can check it’s not
bleeding before it dives back into the
abdomen. If the deep ring has been
widened by this intruder a simple stitch
or two, medially and/or laterally to the
ring will help.
Now, what if you find a direct hernia?
This is much easier; you could just go
straight to the mesh step but it’s usually
Dissection of the sac with the tips of the dis-
secting scissors.
Identification of the sac.
The sac has been dissected from the cord and
is being retracted superiorly with clips whilst a
Lanes retractor is retracting the cord inferiorly.
A Langenbeck retractor exposes the posterior
wall.
4 | General
easier to push the hernia back in with
your finger, thus invaginating it, and then
plicate the posterior wall. This stitch
doesn’t have much strength but it does
make it easier to get the mesh down flat
on the posterior wall. Poke the hernia
back in with your index finger, this creates
a little ridge of tissue (made of a bit of
transversus abdominus and transversalis
fascia) just above and below the tip of
your finger in the medial part of the pos-
terior wall—take a bite of the bottom ridge
and then the top ridge and tie a knot
(obviously taking care not to include
your finger in the stitch). Keep stitching
the bottom ridge to the top ridge until
the hernia is essentially inverted and the
back wall looks flat. Don’t be overly
ambitious with those stitches, trying for
example to stitch strong muscle all the
way down to inguinal ligament—this is
unnecessary and just creates tension
which is not what you want for wounds
to heal. Also don’t place the stitches
too deep; don’t forget that the inferior
epigastric vessels aren’t far behind.
Now for the mesh. Shape it roughly
before inserting it. The corner that will lie
over the pubic tubercle can be rounded
off. Create a slit so that you can wrap it
round the cord—and at the apex of the
slit create a V-shape so that the cord can
fit through.
Stitch or staple the rounded corner
to the tissue lying just over the pubic
tubercle. It’s very important that the
mesh overlaps the pubic tubercle,
and superiorly extends well beyond it,
ideally to the midline—this is where the
Gentle anteroinferior traction on the cord
reveals the posterior wall—here it has been
plicated.
Slit for cord
Stitch to pubictubercle
Stitch to inguinalligament
The shape to cut the mesh into for a right-sided
inguinal hernia. On the left obviously it’s the
mirror image.
The mesh has been inserted with the upper and
lower leaves wrapping around the base of the
cord—the deep ring.
Inguinal Hernia Repair| 5
hernia will recur if you don’t. Hold
the lower part of the mesh down so its
lower edge is right over the inside of the
inguinal ligament. Run a continuous
non-absorbable suture such as 2–0
Prolene, suturing the two together;
alternatively use staples. When you get
to the deep ring, suture or staple the
upper leaf to the lower leaf just lateral to
the deep ring thus re-creating a new deep
ring. Stitch the upper leaf down to the
inguinal ligament. Not much else needs
to be done laterally. Medially, you need to
stitch the edge of the mesh down to the
posterior wall, or staple it. Stretch the
mesh out over the posterior wall so that it
isn’t heaped up or too tight and con-
tinue the suture or staples around the
medial edge onto the superior edge. Take
care to avoid including a nerve in your
suture or staple.
If you’ve got this far and it’s your first
hernia—very well done to you. Now close
up. Re-apply clips to the upper and
lower edges of external oblique and run a
continuous absorbable suture such
as 2–0 Vicryl from lateral to medial or
medial to lateral, thus re-constructing the
external ring. The fascia and fat can be
closed with continuous absorbable
suture and the skin with an absorbable
subcuticular suture.
NotesYou’ll see in the video that on finding an
indirect hernia we don’t do the usual
twisting of the sac, transfixing and
amputating it (which you can see in the
Inguinal Hernias Extras video). This is
because it’s a sliding hernia as evidenced
by the fat (and sometimes retroperitoneal
structures like caecum) you can see in its
wall. This is essentially a prolapse of the
retroperitoneal tissues through the deep
ring, rather than a processus vaginalis. If in
doubt open the sac, if the lining has
attached caecum inside, for instance,
obviously you don’t want to chop that
off, so simply reduce it back to the
abdomen.
In women (see Inguinal Hernia Extras
video), inguinal hernia repairs are consid-
erably easier. They have only rudimentary
structures, principally the round ligament,
passing through their inguinal canal—and
this can be simply ligated and divided.
The hernia can then be invaginated back
into the abdominal cavity and the poster-
ior wall plicated as for a direct inguinal
hernia. You can then apply a piece of
mesh without the usual slit to accommo-
date the cord, directly on to the posterior
wall and stitch or staple it in.
In inguinoscrotal hernias (see Inguinal
Hernia Extras video), the sac passes right
Completed mesh—note the inferior row of
staples have been inserted onto the inside of
the inguinal ligament.
6 | General
through the canal into the scrotum where
it’s usually firmly adherent. Don’t try and
dissect the sac out of the scrotum—this
will just result in lots of bleeding and is
unnecessary. Instead, dissect out the
sac in the usual way from the cord and
transect it, leaving the distal part in the
scrotum, undissected and leave it open.
Any fluid that builds up in the residual sac
will drain out of the hole, so don’t close it
or otherwise you’re effectively giving the
patient a hydrocoele. Deal with the prox-
imal side in the sameway as you would for
any indirect hernia.
Summary� The patient is supine and under general
or local anaesthetic
� The correct groin is shaved, prepped
and draped
� Incise skin above the medial half of the
inguinal ligament
� Incise down to external oblique
� Open external oblique at the level of the
external ring
� Create a plane beneath external
oblique
� Separate cord 1/2 sac from the pubic
tubercle
� Separate cord from sac
� Transfix and amputate indirect sacs
� Plicate posterior wall if bulging
� Shape and insert a mesh securing it,
most importantly, medially
� Close the external oblique
� Close fascia then skin
Inguinal Hernia Repair| 7